Why you need to watch out for copay accumulator programs

The National Psoriasis Foundation’s (NPF) Patient Navigation Center recently received a call from Diego, a New Jersey resident living with psoriatic disease, who was trying to understand why he received a bill of nearly $5,000 from his health insurance company.

This surprise bill was courtesy of a newly implemented health insurance policy usually known as a copay accumulator program. It was introduced in January by Express Scripts, a pharmacy benefits manager (PBM), and other companies that help health plans decide and manage what prescriptions drugs are covered by insurance.

Because of the high cost of treatment, many patients use copay assistance programs provided by drug manufacturers. (Copay assistance programs are run by the manufacturers. They help patients pay for out-of-pocket costs.) These programs provide a copay card, with a fixed dollar amount, that patients use to cover all out-of-pocket expenses – copays or coinsurance – for a specific treatment while trying to reach their deductible (the amount that a patient must pay before their insurance plan begins covering the cost of their medications).

However, copay accumulator programs work against copay assistance programs. Under a copay accumulator program, you can’t apply copay assistance payments for prescriptions toward a patient’s deductible. This means a patient must still pay the full deductible themselves. The average deductible for mid-level plans this year is almost $4,000, which can be unaffordable for many patients.

While these programs are new, they have far-reaching impacts. Reuters reported that around 17 percent of employer health plans with 5,000 or more employees are currently using a copay accumulator. The rapidly increasing popularity of these programs have led to unplanned high out-of-pocket costs and increased concerns among the patient and provider communities. These programs can hurt individuals living with a serious or chronic illness because they exacerbate the challenge of paying for critical treatments.

When your copay card no longer counts

Like many patients, Diego was paying for his treatments by utilizing a copay card capped at $12,000 per year. For the past four years this has allowed Diego to pay for his treatments with only a $15 to $20 monthly out-of-pocket payment. He was shocked and completely unprepared to learn his copay card no longer counted towards to his deductible. After three weeks of numerous calls and emails between his health insurer and PBM, he finally learned that his bill was the result of a copay accumulator program.

“I always thoroughly read information sent from my health care plan. I saw no notice of the accumulator program and was very confused by this extremely high bill,” explains Diego. “Besides the large bill, one of the most frustrating and stressful parts of this process was trying to get any information about the charges from my health insurer or PBM.”

Unfortunately, there was no appealing this decision. Diego was unable to refill his prescription without paying almost $3,000. By May, Diego had depleted his health care savings and now faces paying over $700 a month to continue filling his prescription. To fill his prescriptions for October through December will cost Diego over $2,100. He is still figuring out how to cover the unexpected bill, especially around the holiday season. Diego says, “if I had known about this program, I would have made a different choice when selecting my health care plan.”

Many insured patients are already unable to afford the medical care and the full range of treatments necessary to manage serious, chronic and potentially debilitating diseases including psoriasis and psoriatic arthritis. A 2017 study of data collected from NPF surveys found that although roughly 89 percent of patients with psoriasis or psoriatic arthritis were covered by insurance, a little over half spend more than $2,400 per year in out-of-pocket costs for their disease.

When facing high out-of-pocket costs, patients do not use their medications appropriately, skipping doses in order to save money or abandoning treatment altogether. According to several studies, prescription abandonment rates increase significantly when cost-sharing exceeds $100.

Many voices, one mission

NPF strives to improve health outcomes for those living with psoriatic disease. We continue to track this issue and work to ensure patients are able to afford the therapies necessary to treat their disease.

If you, or someone you know, have encountered large bills as a result of utilizing copay assistance programs, or would like to support our out-of-pocket efforts, please contact Amy Prentice at [email protected] or 503-546-5551. You can also learn more about our advocacy work and about copay accumulators.

Driving discovery, creating community

For more than 50 years, we’ve been driving efforts to cure psoriatic disease and improve the lives of those affected. But there’s still plenty to do! Learn how you can help our advocacy team shape the laws and policies that affect people with psoriasis and psoriatic arthritis – in your state and across the country. Help us raise funds to support research by joining Team NPF, where you can walk, run, cycle, play bingo or create your own fundraising event. If you or someone you love needs free, personalized support for living a healthier life with psoriatic disease, contact our Patient Navigation Center. And keep the National Psoriasis Foundation going strong by making a donation today. Together, we will find a cure.